| NPI | 1912547456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1183049) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-01-13 |
| Last Update Date | 2025-12-01 |